Private Duty Employment Verification Form - Prometric - ct 2026

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The document is a Connecticut Nurse Aide Employment Verification Form used to verify nurse aide or nursing-related employment for maintaining status on the Connecticut Nurse Aide Registry. It requires information from both the nurse aide and their employer, including personal details, employment dates, and a description of duties. The completed form must be submitted directly from the employer to the CT Nurse Aide Registry.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the designated field at the top of the form. Ensure that your current address and telephone number are accurately filled out.
Input your Connecticut Nurse Aide Registration Number and Social Security Number in the respective fields.
If you are certified as a nurse aide in other states, indicate 'Yes' and list those states in the provided space.
Next, move to the section for employer details. The employer should enter their name, address, date of hire, and last reported date of employment.
Employers must describe specific nursing activities performed. If more space is needed, attach an additional sheet.
Finally, ensure that an employer representative signs and dates the form before submission.

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